Sézary syndrome (SS) is an aggressive leukemic form of cutaneous T-cell lymphoma (CTCL) that is clinically characterized by pruritic erythroderma, generalized lymphadenopathy, and the presence of neoplastic, clonally related, CD4+ T cells in the skin, lymph nodes, and peripheral blood (PB). Despite advances in therapy, the prognosis remains poor, with a 5-year overall survival of 30% (Willemze, 2019). The malignant cells (Sézary cells) exhibit heterogeneous aberrant immunophenotypes most commonly involving the loss of CD2, CD7, and CD26 and the upregulation of immune checkpoint receptor programmed cell-death (PD-)1 (CD279) and the killer cell immunoglobulin-like MHC receptors (KIR) CD158k (Çetinözman et al., 2014Çetinözman F. Jansen P.M. Willemze R. Expression of programmed death-1 in skin biopsies of benign inflammatory vs. lymphomatous erythroderma.Br J Dermatol. 2014; 171: 499-504Crossref PubMed Scopus (24) Google Scholar; Di Raimondo et al., 2022Di Raimondo C. Rubio-Gonzalez B. Palmer J. Weisenburger D.D. Zain J. Wu X. et al.Expression of Immune Checkpoint Molecules PD1, PD-L1 and ICOS in Mycosis Fungoides and Sézary Syndrome: Association with Disease Stage and Clinical Outcome.Br J Dermatol. 2022; Crossref PubMed Scopus (3) Google Scholar; Najidh et al., 2021Najidh S. Tensen C.P. van der Sluijs-Gelling A.J. Teodosio C. Cats D. Mei H. et al.Improved Sézary cell detection and novel insights into immunophenotypic and molecular heterogeneity in Sézary syndrome.Blood. 2021; 138: 2539-2554Crossref PubMed Scopus (18) Google Scholar; Nguyen et al., 2017Nguyen G.H. Olson L.C. Magro C.M. Upregulation of inhibitory signaling receptor programmed death marker-1 (PD-1) in disease evolution from cutaneous lymphoid dyscrasias to mycosis fungoides and Sezary's syndrome.Ann Diagn Pathol. 2017; 28: 54-59Crossref PubMed Scopus (0) Google Scholar; Querfeld et al., 2018Querfeld C. Leung S. Myskowski P.L. Curran S.A. Goldman D.A. Heller G. et al.Primary T Cells from Cutaneous T-cell Lymphoma Skin Explants Display an Exhausted Immune Checkpoint Profile.Cancer Immunol Res. 2018; 6: 900-909Crossref PubMed Scopus (58) Google Scholar; Samimi et al., 2010Samimi S. Benoit B. Evans K. Wherry E.J. Showe L. Wysocka M. et al.Increased programmed death-1 expression on CD4+ T cells in cutaneous T-cell lymphoma: implications for immune suppression.Arch Dermatol. 2010; 146: 1382-1388Crossref PubMed Scopus (112) Google Scholar; Wada et al., 2011Wada D.A. Wilcox R.A. Harrington S.M. Kwon E.D. Ansell S.M. Comfere N.I. Programmed death 1 is expressed in cutaneous infiltrates of mycosis fungoides and Sézary syndrome.Am J Hematol. 2011; 86: 325-327Crossref PubMed Scopus (0) Google Scholar). The underlying mechanisms by which these aberrant immunophenotypes arise are not fully elucidated. An epigenetic mechanism responsible for deregulated gene expression and subsequent aberrant protein expression in CTCL involves the hyper-or hypomethylation of CpG sites in or near the promoter CpG island region.(Tensen et al., 2022Tensen C.P. Quint K.D. Vermeer M.H. Genetic and epigenetic insights into cutaneous T-cell lymphoma.Blood. 2022; 139: 15-33Crossref PubMed Scopus (16) Google Scholar). Using the Illumina 450K array platform, we previously showed that the genome-wide DNA methylation profiles of CD4+ T cells from SS patients were distinct from those of patients with benign erythroderma (BE) and healthy controls (HC) (van Doorn et al., 2016van Doorn R. Slieker R.C. Boonk S.E. Zoutman W.H. Goeman J.J. Bagot M. et al.Epigenomic Analysis of Sézary Syndrome Defines Patterns of Aberrant DNA Methylation and Identifies Diagnostic Markers.J Invest Dermatol. 2016; 136: 1876-1884Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). Herein, we selected gene PDCD1 (encoding PD-1) which is of particular interest given its frequently aberrant protein expression levels in SS and with potentially important implications in pathogenesis and/or of diagnostic, therapeutic, and prognostic value. To this end, we performed combined analyses of DNA methylation, gene, and protein expression in a large cohort of SS patients. We first assessed the DNA methylation status of gene promoter locus PDCD1 using methylation-specific melting curve analysis (MS-MCA). Following approval from the ethical committee of Leiden University Medical Center, we collected PB samples from 38 patients with SS, 10 BE, and 4 HCs (Tables S1/S2). All individuals provided written informed consent. We performed peripheral blood mononuclear cell (PBMC) isolation, CD4+ T-cell enrichment by MACS cell depletion of non-CD4+ T cells, DNA isolation, DNA bisulfite conversion, and MS-MCA on bisulfite-converted DNA (detailed in Supplementary Methods). Qualitative assessment of the methylation data showed that the PDCD1 gene promoter was markedly hypomethylated in SS samples as compared to BE/HC samples (Figure 1a). The majority of SS samples (81%, 35/43) showed a partially (n=24), or completely (n=11) hypomethylated PDCD1 gene promoter. In contrast, the PDCD1 gene promoter was methylated in all BE/HC samples. We further examined the corresponding gene and protein expression levels. We applied relative gene expression analysis on CD4-enriched T lymphocytes from PB of 36 SS and 6 BE samples by using qPCR analysis of PDCD1. Stratification of SS patients into cases with hypomethylated (n=30) or predominantly methylated (n=6) PDCD1 gene promoters showed a significant inverse correlation between PDCD1 methylation status and mRNA levels. The average PDCD1 promoter mRNA levels among SS samples with hypomethylated gene promoters demonstrated a significantly higher expression when compared to methylated gene promoters from SS (p=0.0027) or BE (p=0.0232) samples (Figure 1b). The PDCD1 gene expression levels in the latter groups were comparable (p=0.3496). Next, we reviewed PD-1 protein expression in skin biopsies by immunohistochemistry (IHC). In 42 available SS skin biopsies–37 initial and 5 follow-up– membranous PD-1 expression was present in the majority of cases (86%, 36/42). For the latter, the presence of PD-1 protein expression on neoplastic CD4+ T cells in skin correlated with hypomethylated PDCD1 gene promoters (MS-MCA) on total circulating CD4+ T cells (92%, 33/36). Likewise, negative PD-1 protein expression correlated with a (predominantly) methylated gene promoter (83%, 5/6). PD-1 was hardly expressed in the two BE skin biopsies that were available for IHC staining. Interestingly, in two of five SS patients with paired diagnostic and follow-up skin biopsies, we observed reduced PD-1 expression in the follow-up compared to the initial biopsy. These changes in PD-1 expression corresponded with an altered methylation pattern of the PDCD1 gene promoter. This is illustrated for a SS case for which additional analyses were performed on the PD-1 protein expression on neoplastic CD4+ T cells in the skin (IHC) and PB (flow cytometry) (Figure 2, Figure S1 and S2). PD-1 is normally expressed on immune-competent hematopoietic cells and, following binding with one of its two natural ligands PD-L1/PD-L2, it attenuates antitumor immunity through the inhibition of T-cell activation. Conversely, unlike the majority of lymphoid malignancies (Kornepati et al., 2022Kornepati A.V.R. Vadlamudi R.K. Curiel T.J. Programmed death ligand 1 signals in cancer cells.Nat Rev Cancer. 2022; 22: 174-189Crossref PubMed Scopus (53) Google Scholar), tumor cell-intrinsic PD-1 expression is a common feature of Sézary cells whereas its ligands are often confined to small tumor-cell subsets (Di Raimondo et al., 2022Di Raimondo C. Rubio-Gonzalez B. Palmer J. Weisenburger D.D. Zain J. Wu X. et al.Expression of Immune Checkpoint Molecules PD1, PD-L1 and ICOS in Mycosis Fungoides and Sézary Syndrome: Association with Disease Stage and Clinical Outcome.Br J Dermatol. 2022; Crossref PubMed Scopus (3) Google Scholar). Similarly, PD-1 is generally not expressed by non-neoplastic T cells present in the lymphoma microenvironment. Herein, we report on the dynamic epigenetic regulation of PD-1 expression in SS through (hypo)methylation of the PDCD1 gene promoter. We found a consistent inverse correlation between PDCD1 gene promoter methylation, PDCD1 gene expression, and PD-1 membranous protein expression. Together with the reversible character of PDCD1 methylation as observed in follow-up samples, these data imply an active causative role rather than a correlative one, which is in line with the epigenetic regulation of PDCD1 as described in normal T cells undergoing maturation (Bally et al., 2026). Nonetheless, it is unlikely that the evident hypomethylation signature across SS samples is merely reflective of normal T-cell development as we did not observe this phenomenon in BE/HC samples. These data cannot rule out other potential molecular mechanisms involved. Furthermore, the precise functional consequences of upregulated PD-1 expression and its significance for the future application of immunotherapies in CTCL remain to be discovered. Accordingly, while therapeutic blockade of PD-1/PD-L1/L2 interactions has been successfully exploited in several (hematopoietic) malignancies, results in CTCL are variable and inconclusive thus far (Khodadoust et al., 2020Khodadoust M.S. Rook A.H. Porcu P. Foss F. Moskowitz A.J. Shustov A. et al.Pembrolizumab in Relapsed and Refractory Mycosis Fungoides and Sézary Syndrome: A Multicenter Phase II Study.J Clin Oncol. 2020; 38: 20-28Crossref PubMed Scopus (117) Google Scholar). These variable results illustrate that these therapies may not only lead to the activation of reactive T cells but also PD-1-expressing tumor cells. In this regard, the additive use of DNA methyltransferase inhibitors, that further stimulate hypomethylation, might impair the efficacy of PD-(L)1 inhibitors and should be used with caution. Moreover, in the pursuit of biomarkers to predict responsiveness to immunotherapies targeting the PD-1/PD-L1 axis in CTCL, several biomarkers have been explored including the assessment of PD-(L)1 expression (Di Raimondo, 2022), PD-L1 structural variants as genomic biomarkers (Beygi et al., 2021Beygi S. Fernandez-Pol S. Duran G. Wang E.B. Stehr H. Zehnder J.L. et al.Pembrolizumab in mycosis fungoides with PD-L1 structural variants.Blood Adv. 2021; 5: 771-774Crossref PubMed Scopus (13) Google Scholar) and a spatial biomarker (SpatialScore) reflecting the functional immune state of the tumor microenvironment (Philips et al., 2021). In line, the PDCD1 (hypo)methylation status might potentially serve as a predictive biomarker of PD-1 activation and its clinical importance should be further investigated in future studies. The authors declare no conflicts of interest. Bally et al., 2016Bally A.P. Austin J.W. Boss J.M. Genetic and Epigenetic Regulation of PD-1 Expression.J Immunol. 2016; 196: 2431-2437Crossref PubMed Google Scholar, Phillips et al., 2021Phillips D. Matusiak M. Gutierrez B.R. Bhate S.S. Barlow G.L. Jiang S. et al.Immune cell topography predicts response to PD-1 blockade in cutaneous T cell lymphoma.Nat Commun. 2021; 12: 6726Crossref PubMed Scopus (34) Google Scholar, Willemze et al., 2019Willemze R. Cerroni L. Kempf W. Berti E. Facchetti F. Swerdlow S.H. et al.The 2018 update of the WHO-EORTC classification for primary cutaneous lymphomas.Blood. 2019; 133: 1703-1714Crossref PubMed Scopus (605) Google Scholar. The authors thank the patients and healthy controls who participated in the study. Data Availability Statement All relevant data analyzed during this study are included in the main text and the supplementary files. Author Contributions Conceptualization: SN, WHZ, CPT, and MHV; Investigation and analysis: SN, WHZ. Data analysis - histopathology: AMRS and RW. Supervision: CPT and MHV. Writing – original draft: SN; Writing – review and editing: all authors. All authors participated in discussions and data interpretation and approved the final version of the manuscript. Download .pptx (26.89 MB) Help with pptx files Download .pptx (.1 MB) Help with pptx files Download .xlsx (.02 MB) Help with xlsx files Download .xlsx (.01 MB) Help with xlsx files Download .docx (.02 MB) Help with docx files